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«Member Handbook UWV-MHB-0003-14 12.14 Dear Member: Welcome to UniCare Health Plan of West Virginia, Inc.! This is your member handbook. Here, you ...»

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We’re here to help; If you feel your PHI hasn’t been kept safe, you may call the  or contact the DHHR at 1-877-716-1212. Nothing bad will happen to you if you complain.

We reserve the right to change this notice and the ways we keep your PHI safe. If that happens, we’ll tell you about the changes in a newsletter; We’ll also post them on the Web at unicare.com/medicaid.

As we told you in our Health Insurance Portability and Accountability Act (HIPAA) notice, we must follow state laws if they say we need to do more than the Federal HIPAA Privacy Rule. This notice tells you about your rights and what the state laws say we have to do.

unicare.com/medicaid We can translate this for you at no cost. Call the Customer Care Center at 1-800-782-0095.

If you have speech or hearing loss, call the TTY line at 1-866-368-1634.

–  –  –

 We may use your PI to make decisions about your:

– Health – Habits – Hobbies  We may get PI about you from other people or groups like:

– Doctors – Hospitals – Other insurance companies  We may share PI with people or groups outside of our company without your OK in some cases.

 We’ll let you know before we do anything where we have to give you a chance to say no.

 We’ll tell you how to let us know if you don’t want us to use or share your PI;

 You have the right to see and change your PI.

 We make sure your PI is kept safe.

unicare.com/medicaid We can translate this for you at no cost. Call the Customer Care Center at 1-800-782-0095.

If you have speech or hearing loss, call the TTY line at 1-866-368-1634.

–  –  –

You may choose one PCP for your whole family, or each family member may choose a different PCP. You must list each family member on the form even if you select the same PCP. We will send you new ID cards within five days after we receive your completed form. Always carry your ID card with you.

□ Please check this box if you are pregnant.

When you are done filling out this form, just mail it back in the envelope we provided. No stamp is needed.

Choose the PCP who’s right for you. Send this form back today!

Look in our Provider Directory and give us your first and second choices for a PCP. Please print your information below.

Your Name (please print):

–  –  –

□ Please check this box if you have moved in the last year; If you move, please remember to call our Customer Care Center at 1-800-782-0095.

Your Daytime Telephone Number:

Your Signature:

unicare.com/medicaid

–  –  –

Member Name (First and Last):

Member ID Number:

First Choice — PCP Name (First and Last):

Second Choice — PCP Name (First and Last): _____ unicare.com/medicaid

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